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Chapter 20 • Limb Pain 251
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annular lesion with a clear center. Concentric rings
may develop, giving it a bull’s-eye appearance (erythema migrans).
Look for a puncture or an abscess that could be
the source of infection and seeding if a septic joint or
osteomyelitis is suspected. Swelling and redness in a
joint or in the midshaft of the tibia may be caused by
osteomyelitis.
Look for an ingrown toenail that may alter gait.
When the nails are trimmed by rounding off the edges,
the hypertrophied and inamed soft tissue fold can
overlap the nail, and ingrowth at the distal margin will
occur. Ingrown toenail pain is enhanced when tighttting shoes compress the soft tissues around the nail.
Look for ecchymosis and bruising. These indicate
trauma as a source for pain as well as raise a suspicion
of abuse. Ecchymosis indicates underlying bleeding
and disruption of soft tissue or bone. Ecchymosis
changes color over a period of days. Initially the color
is dark red or violet, and in 1 to 3 days the bruise is
blue-brown; in 1 week, it is yellow-green; and after
1 week, it is light brown. Ecchymosis resolves within
2 to 4 weeks.
Ecchymosis in the popliteal fossa after dislocation
of the knee may be a sign of arterial disruption. Hemarthrosis, or bleeding into a joint, usually occurs within
1 to 2 hours after an injury and can occur secondary to
hemophilia or other bleeding disorders, or it can be
associated with visible ecchymoses caused by blood
leaking into soft tissues.
Swelling and redness of a joint indicate underlying
infection or inammation. Edema will present as an
asymmetrical area of swelling. Effusion, or uid in the
joint capsule, always distends the joint in a smooth,
symmetrical manner.
Observe the muscles around the painful limb area.
Decreased muscle tone or atrophy from disuse begins
immediately after injury; however, it will not be clinically apparent for approximately 1 week.
Asymmetrical gluteal folds may indicate a congenital
dislocated hip (Figure 20-6).
Measure Limb Circumference and Length
Use a tape measure to locate points at which to measure and compare limb circumference. Differences
may be the result of muscle atrophy or edema. To measure leg length, have the patient lie supine with legs in
comparable positions and measure the distance from
the anterior iliac spines to the medial malleoli of the
ankles. If a discrepancy is found, ask the patient to lie
supine with knees exed 90 degrees and feet at on the
table. If one knee is higher, the tibia of that extremity
is longer. If one knee projects further anteriorly, the
femur of that extremity is longer.
Palpate Extremities and Joints
Always palpate those areas that are suspected to be
painless rst and then compare with the affected limb.
Determine if there is edema (e.g., presence of interstitial uid). Induration is interstitial swelling that has
progressed and is now rm. An effusion is a collection
of uid in the joint capsule, which can be the result of
rupture of a vascular structure or a synovial secretory
response to an inammatory process. The consistency
of the uid is noteworthy. Pus has a thick consistency
and is less uctuant than synovial uid. Hematoma has
a more gel-like consistency. Swelling in an ankle
sprain is diffuse and nonuctuant. Knee ligament
sprain is much more uctuant. To assess for uid in the
knee joint, press above the knee and watch the concave
A
FIGURE 20-6 Ortolani sign for congenital dislocation of the hip. A “click” is
palpable or audible as the hip is reduced by abduction. If the test is negative, the
examination should always be repeated in 2 to 4 months. (From Mercier LR:
Practical orthopedics, ed 6, St Louis, 2008, Mosby.)
B
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or shallow areas of the joint become distended and
bulge on either side of the kneecap. Note that swelling
can extend above and below the point of pathology.
In severe knee trauma, rupture of the capsule allows
uid to escape into surrounding tissues, and less distention may be more apparent than with lesser injuries.
Palpate for uid bulge if the knee is painful. Milk
the uid up into the suprapatellar pouch and then bring
the hand down the lateral aspect of the knee looking for
a medial uid bulge. Palpate deeply to detect muscle
brillation, fasciculation, or tumors.
Feel for heat in the affected joint, which can indicate an inammatory or infectious process. Evaluate
the joint for crepitus, both palpable and auditory. Tendinitis can produce a grating sensation on palpation of
the ligament or a grating sound with movement.
Perform Passive/Active Range of Motion
of All Limbs
Range of motion (ROM) may be limited because of
pain, weakness, or deformity.
If pathology is in the joint, pain will be the same
with active and passive motion. If the disease is outside
the joint or extraarticular, passive motion may be painless while active motion produces pain. During passive
tests, move the joint until an end point or end range is
felt to help determine the affected structure and the
severity of the injury.
There are six end points to note when assessing
joint movement: (1) bone-to-bone sensation, felt
with an osteophyte or abnormal bone development;
(2) spasm, which can indicate severe ligamentous
injury; (3) capsular feel or a rm arrested movement,
with some give to it, which can indicate chronic joint
effusion, arthritis, or capsular scarring; (4) spring
block, or joint rebound at the end of range of movement, caused by an articular derangement or an intraarticular body; (5) tissue approximation, a normal
end feel caused by tissue limiting further movement,
such as the biceps muscle limiting elbow exion; and
(6) empty end feel, present when there is no tissue
resistance, but the patient stops the movement because of pain. This last condition indicates bursitis,
extraarticular abscess, or tumor.
Test for Muscle Strength
Test for exor and extensor strength against resistance of both the proximal and distal muscle groups.
Proximal muscle weakness is seen in myopathic
disorders. Distal muscle weakness is seen secondary
to a neuropathic process. Generally, if the opposite
side is normal, strength should be compared to it.
A scale of 0 to 5 is used to rate muscle strength
(Table 20-1).
In the presence of signicant pain, muscle strength
may be unreliable. If the contraction is strong and
painful, the pathology is caused by mild musculotendinous damage. If the contraction is weak and painful, the pathology is the result of severe musculotendinous damage. If the contraction is weak and
painless, the pathology results from a neurological
lesion (paresis).
Perform a Neurological Examination
A complete assessment of sensory and motor function
and deep tendon reexes should be done on the affected
and contralateral limbs. If systemic illness is suspected,
perform a complete neurological examination. A referral is indicated if initial treatment does not adequately
control pain, if function loss is progressing, or if the
patient is immunocompromised.
LABORATORY AND DIAGNOSTIC
STUDIES
Complete Blood Count
A complete blood count (CBC) is obtained to evaluate
for anemia associated with chronic disease, infection,
or neoplasm. An altered white blood cell (WBC) count
may indicate infection or leukemia.
Erythrocyte Sedimentation Rate
An erythrocyte sedimentation rate (ESR) is elevated
when inammation is present. It is a nonspecic test.
Table 20-1
GRADE MUSCLE STRENGTH TERM
0 No palpable contraction Zero
1 Muscle contracts but part
2 Muscle moves part but not
3 Muscle moves part through
4 Muscle moves part even
5 Normal strength against
Muscle Strength Test
Trace
does not move
Poor
against gravity
Fair
range against gravity
Good
with resistance
Excellent
resistance present
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Joint Aspiration
Joint aspiration is performed to assess synovial uid
for elevated WBC count, Gram stain, culture and sensitivity, crystal analysis, presence of glucose, and consistency or “string test.” This procedure is performed
using local anesthesia under sterile technique. Synovial uid will ow easily when the joint capsule is
penetrated.
Radiography
Obtain at least two radiographic views, anteroposterior and lateral, because injuries are not always apparent on a single view. Any evidence of fracture or
dislocation will require orthopedic attention. Sometimes radiographic comparisons with the opposite
limb may be useful. Traumatic knee injuries should
include four radiographic views: anteroposterior, lateral, tunnel (intracondylar notch), and a 30-degree
sunrise (patella). Other diagnostic imaging techniques
such as magnetic resonance imaging (MRI), computed tomography (CT), or bone scanning are usually
ordered by a specialist. MRI is usually used in spine,
joint, and soft tissue imaging. CT scans are usually
performed for bone visualization.
Antinuclear Antibodies
Antinuclear antibody (ANA) tests are positive with
high titers in RA and SLE; however, other conditions,
such as aging, medications, and other connective tissue
disease, can produce positive antibody titers.
Rheumatoid Factor
Rheumatoid factor (RF) is the single most useful test to
conrm a diagnosis of RA and is positive in 80% of
patients with this disease.
C4 Complement
C4 complement determines serum hemolytic complement activity, a protein that binds antigen-antibody complexes for the purpose of lysis. Complement is increased
in active inammatory disease and in autoimmune disorders such as juvenile RA.
C-Reactive Protein
C-reactive protein (CRP) indicates the presence of
abnormal plasma protein or a nonspecic response to
inammation caused by both infectious and noninfectious processes. CRP is elevated in RA and infection.
Lyme Titer Enzyme-Linked
Immunosorbent Assay Serology
Enzyme-linked immunosorbent assay (ELISA) detects
antibodies against B. burgdorferi, which causes Lyme
disease. However, the ELISA may not detect antibodies
for several weeks after the onset of infection.
DIFFERENTIAL DIAGNOSIS
Musculoskeletal Inflammation
Tenosynovitis (Tendinitis)
Soft tissue disorders of tendinitis, bursitis, and bro-
sitis tend to co-occur. Tenosynovitis is a term that
refers to inammation of the tendon and tendon
sheath. In an acute inammation, usually caused by
trauma related to recreational or occupational activi-
ties, effusion may accumulate and result in swelling;
with chronic inammation, ROM will be limited by
brosis of the tendon sheath.
The patient’s chief complaint will be pain that
is worse with movement and swelling around the
affected area. Occupational and recreational history
will provide vital clues to a traumatic or overuse cause
of pain. Persons with arthritis may have tendinitis secondary to joint disease. Crepitus may be felt on palpation of the tendon.
Bursitis
Bursitis is inammation of a sac lined with synovial
uid, most often secondary to traumatic tenosynovitis
of the shoulder, hip, knee, and elbow. Numerous bursae
lie over bony prominences and reduce friction from
motion of fascial planes. Bursitis is caused by overuse
and trauma and may be associated with RA. If isometric
contraction of a group of muscles causes pain, the
muscles or tendons, or both, may be involved. Bursitis
causes an aching pain that radiates to points of tendon
insertion or further along the limb. Muscle weakness
may also be present. Palpation reveals local tenderness
and swelling without full range of joint motion.
Fibrositis (Myofascitis, Fibromyositis)
Fibromyositis is a response to underlying conditions,
such as polymyalgia rheumatica, RA, ankylosing spondylitis, hypothyroidism, neuritis, and viral infection, that
generate major muscle tension around a large, weightbearing proximal joint. Fatty and brous nodules may
be palpable, and painful trigger sites can be located
throughout the shoulder and pelvic girdles or lower
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extremities. Patients complain of stress and anxiety,
sleep disturbance, painful trigger points, and joint
stiffness.
Osteomyelitis
The presentation of osteomyelitis, a pyogenic infection
of bone, depends on the age of the patient as well as the
bone involved. This condition should be suspected in
any patient who complains of pain in long or at bones
and walks with an antalgic limp. Fever, chills, and
vomiting are usually present in acute osteomyelitis but
may not occur in the neonate or young infant. Chronic
osteomyelitis is characterized by relapse of pain, erythema, swelling, or evidence of purulent discharge.
The hallmark is a constant local pain that progressively
worsens. The slightest motion of the limb aggravates
the pain. The child keeps the limb motionless. Laboratory ndings show increased WBCs, ESR, and CRP.
Radiographs may show bone destruction or deep soft
tissue swelling at the site of infection.
Joint Inflammation
Osteoarthritis
Osteoarthritis (OA) is a degenerative disease of joint
cartilage that results in osteophyte (spur) development
and synovial inammation. It is the most common
form of arthritis and is present to some extent in
all elderly persons. Patients will complain of joint stiffness, pain, and limited movement, most often of
the spine (cervical and lumbar), large proximal joints
(e.g., knee, hip), and PIP joints. Symptoms may be
asymmetrical. Heberden nodes develop on the DIP
joints. Patients at increased risk have a history of performing repetitive weight-lifting tasks, have sustained
some form of joint trauma, are obese, or have been
diagnosed with diabetes mellitus. Acute arthritis is
associated with an increased ESR, and radiographs will
show spurs, joint deformity, and erosive changes.
Rheumatoid Arthritis
RA is a systemic polyarthritis with a wide spectrum of
clinical presentation. Symptoms of RA include morning
stiffness of symmetrical small joints in the hands and
feet, swelling, and progressive fatigue. Other symptoms
include fever, weight loss, anorexia, and diaphoresis.
Rheumatoid nodules are soft and spongy and appear on
the elbows, forearms, and hands. Pericarditis, pleuritis,
and vasculitis are associated conditions. Laboratory data
may disclose a normochromic, normocytic anemia, an
elevated ESR, and a positive rheumatoid factor in 75%
to 90% of patients. Radiographs may show bony erosion
at the joint margins and joint deformities. Box 20-1 lists
criteria for the diagnosis of RA.
Juvenile Rheumatoid Arthritis
Juvenile rheumatoid arthritis (JRA), the most common
connective tissue disease in children, presents with
fatigue, low-grade fever, weight loss, and failure to
grow. Night pain and morning stiffness that improve
with activity are common symptoms. Younger children
may present with irritability, refusal to walk, or guarding of a joint. The disease may be systemic, affect fewer
than four joints (pauciarticular), or affect more than
four joints (polyarticular). Laboratory ndings show
anemia, leukocytosis, and thrombocytosis. Rheumatoid
factor and ANA may be negative. ESR is elevated.
Septic Arthritis
Septic arthritis is sudden pain and inammation of a
single joint, sometimes associated with systemic signs
such as fever, malaise, and diaphoresis. The hip is a
common site of blood-borne joint infection in neonates,
infants, and young children. The presentation depends
on the age of the child. A neonate may be afebrile but
irritable, refusing to feed and failing to gain weight. In
the older child, the onset of pain and fever is acute, and
the child refuses to bear weight. ROM of the hip is
markedly restricted and very painful.
In adults, migratory joint pain and tenosynovitis
may follow 2 to 4 weeks after a mucosal site infection
with Neisseria gonorrhoeae. Knee, wrist, ankle, and
Box 20-1
Diagnostic Criteria for
Rheumatoid Arthritis (Four
Criteria Must Be Present)
• Morning stiffness at least 1 hour before improvement
for more than 6 weeks
• Arthritis of three or more joints for more than 6 weeks
• Arthritis of hand joints for more than 6 weeks
• Symmetrical arthritis of same joint
• Rheumatoid nodules
• Positive serum rheumatoid factor
• Radiographic changes showing erosions or bony
decalcification
Modified from Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF,
Cooper NS et al: The American Rheumatism Association 1987 revised
criteria for the classification of rheumatoid arthritis, Arthritis Rheum
31:315, 1988.
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hand joints are most commonly affected. Joint aspiration shows increased WBCs, and culture of uid or pus
may reveal bacterial, tubercular, fungal, syphilitic, and
viral organisms. The ESR and CRP are also elevated.
With hip involvement, ultrasound shows marked distention of the hip joint, with varying degrees of femoral hip displacement. Septic arthritis is an emergency
situation, and treatment must be initiated immediately.
Gout
Gout is a joint inammation caused by deposits of urate
crystals and is associated with an inborn error of uric acid
secretion or with metabolic disorders (e.g., hemolytic
anemia, renal insufciency, sarcoidosis). Males older
than 30 years and persons with a family history of gout
are most often affected. The patient reports a recurrent,
sudden onset of pain early in the morning that subsides
over several days, especially of the rst MTP joint. The
joint is warm, tender, and red; tophi—chalky subcutaneous deposits of sodium urate—may be present on extensor surfaces. Gout can be differentiated from pseudogout
by the presence of calcium pyrophosphate crystals, involvement of large joints, and secondary osteoarthritis.
Laboratory ndings during an acute attack show elevated
serum uric acid levels, ESR, and WBC levels. The joint
may be aspirated for uid to observe uric acid crystals
and cultured to exclude septic arthritis.
Musculoskeletal Pain Related to Trauma
or Overuse
Shoulder
Dislocation (glenohumeral joint instability). A
patient with shoulder dislocation presents with anterior
and/or posterior joint pain, periarticular muscle spasm,
anxiety, and limited movement. An anterior dislocation
causes inability to internally rotate and abduct the humerus. Posterior dislocation causes limitation of external rotation, arm abduction, and hand supination with
the shoulder exed forward. Radiographs of the shoulder (anteroposterior, lateral, and axillary views) will
exclude fracture of surrounding bones.
Acromioclavicular joint injury. Acromioclavicular joint injuries usually result from sports injuries or
motor vehicle accidents. Injury occurs when the acromion, scapula, and upper extremity are driven inferiorly,
and the supporting ligamentous structures are sprained
or torn. The severity of injury is classied into three
grades: partial tear (dislocation) of the acromioclavicular ligament (I); partial tear of the acromioclavicular
and coracoclavicular ligaments (II); and complete rupture of the acromioclavicular and coracoclavicular ligaments and joint separation (III). History will reveal the
nature of the injury. The patient will have pain and limited shoulder movement and may present with obvious
deformity if there is a severe injury.
Bicipital tendinitis. Bicipital tendinitis is an overuse syndrome of the biceps brachii muscle that ends in
two tendons—one attached to the radial tuberosity
(arm adduction) and one to the forearm fascia (arm
abduction and internal rotation). The syndrome may be
associated with other shoulder disorders, such as impingement syndrome. Children may have anomalies of
the intertubercular groove, and younger individuals
report repeated trauma from swimming, volleyball,
baseball, or golf. Pain is localized to the intertubercular
groove, is aggravated by the offending movement, and
subsides with rest. A Yergason test can indicate bicipital tendinitis. A positive test is characterized by pain in
the intertubercular groove with resistance to supination
of the forearm while the elbow is exed 90 degrees. A
Fisk radiographic view enables the examiner to determine the size of the intertubercular groove.
Rotator cuff tear. Rotator cuff tears are acute
injuries in children and young adults but occur as
chronic injuries in older adults. In acute tears, the
shoulder pain is severe, and the patient is unable to
raise the arm sideways because of pain. In a complete
tear, attempts to raise the arm laterally will produce a
shoulder shrug. In a partial tear, the patient can raise
the arm but cannot maintain the position with any
resistance. Inammation secondary to injury can
cause rotator cuff tendinitis that produces shoulder
pain, weakness, and a grating sound with movement.
Chronic rotator cuff tears are most common in persons older than 50 years, the result of cumulative and
repeated impingement processes. The onset of pain is
insidious and is made worse with the arm in an overhead position. Patients experience shoulder pain with
sleep and tenderness over the acromioclavicular joint.
Examination may reveal minimal restriction in movement, crepitus, and weakness in external rotation of the
shoulder. Radiographs will show any bony abnormality such as an acromial spur.
Elbow
Olecranon bursitis. Olecranon bursitis is commonly seen in patients who engage in contact sports,
repetitive motion, rubbing or pressure to the elbow, or
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overuse. Pain is localized over the bursae, and swelling
may be the result of hemorrhage in a traumatic injury.
Range of joint motion is usually normal. The joint may
be warm and red. When these signs are present, carefully examine the skin over the elbow to ensure intactness, because a penetrating injury may cause a septic
bursitis. Radiography will exclude underlying bone
infection and show the plane of soft tissue swelling.
Lateral humeral epicondylitis (tennis elbow).
Epicondylitis is an aseptic inammation of the bonetendon junction, resulting from repetitive concentric
contractions that transmit force via the muscles to the
origin on the lateral epicondyle. Persons most at risk for
tennis elbow are the nonathletes who have occupations
that require repeated contractions of extensor and supinator muscles. Athletes at risk are tennis players, bowlers, and hockey players. Patients present with gradual
onset of pain and tenderness over the lateral epicondyle
that progresses in intensity. Palpation over the lateral
epicondyle produces point tenderness, although elbow
movement is not limited. Resisted forearm supination
with the elbow exed at 90 degrees will intensify symptoms.
Subluxation of the radial head (nursemaid’s
elbow). Subluxation of the radial head is caused by a
rapid upward pulling of the child’s hand or wrist. The
radial head is pulled out of the annular ligament. This
ligament then becomes caught between the radial head
and the joint, causing the elbow to be exed and pronated. The child cries at the event and then refuses to
move the arm and may complain of pain in the elbow.
Radiographs are normal.
Wrist and Hand
Wrist fracture. Wrist fractures usually are the result of falling on an outstretched hand and may involve
a number of types of fracture. Patients present with a
painful, swollen distal forearm and wrist and may complain of numbness if the median nerve is involved.
Gently palpate to locate the site of maximal pain, particularly the navicular (“snuffbox”) area located between the extensor pollicis longus and the extensor
pollicis brevis tendons when the mechanism of injury
is hyperextension of the wrist. Pain localized here indicates a scaphoid (navicular) fracture. Assess pulses,
pain sensation, and motor function (range and strength).
Radiographic views (posteroanterior, lateral, and
oblique) will reveal the bone involved. In a Colles
fracture, the distal radius is displaced dorsally and
shows up as a “silver fork” deformity on lateral view
radiographs.
Finger fracture. The most common fractures of
the ngers are those of the metacarpals and phalanges,
commonly seen in sports injuries. Older persons usually sustain fractures as a result of falls. Correct diagnosis of a fractured nger is important in preventing
long-term disability of use. Patients will present with a
history of trauma or injury. Physical examination includes assessment of vascular and neurological function, tenderness and swelling, ROM of each joint, and
signs of joint instability or deformity. Three radiographic views (posteroanterior, lateral, and oblique)
are needed for a complete evaluation.
Ganglion. Ganglions are cysts that contain a gelatinous uid formed by outpouching of a joint capsule or
tendon sheath. They most often occur on the dorsum of
the wrist. A ganglion can be distinguished from a tumor
by its soft consistency and transillumination.
Hip and Leg
Slipped capital femoral epiphysis. In children
undergoing a rapid growth spurt, the onset of knee
pain, an antalgic limp, and leg weakness may indicate
a slipped capital femoral epiphysis (SCFE). Pain may
be of several weeks’ or months’ duration and is exaggerated by strenuous physical activity. Examine the
child in a prone position and assess the symmetry of
medial rotation of the hip. A reduction of medial rotation may indicate SCFE. A widening of the epiphyseal
plate can be visualized in a lateral view radiograph.
Transient synovitis of the hip. A nonspecic
inammatory condition of the hip, transient synovitis
is the most common cause of a painful hip in children
younger than 10 years. History may reveal a recent
upper respiratory tract infection or minor injury. The
child complains of pain in the anteromedial aspect of
the thigh and knee and walks with an antalgic limp;
there is tenderness on palpation over the anterior aspect of the hip joint. Movement of the hip causes
pain and is limited. There may be a low-grade fever.
Ultrasound should be used for diagnosis, comparing
it with the good hip. WBC count is usually normal,
although the ESR may be elevated.
Legg-Calvé-Perthes disease. This disease occurs
as osteochondritis of the femoral head epiphysis and
is characterized by a period of avascular necrosis of
the femoral head, followed by revascularization and
bone healing. It occurs most commonly in boys
between the ages of 3 and 11 years. The child has groin
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or medial thigh pain and a limp. The pain may be recurring, and the child may have been limping for several months. The loss of medial hip motion is an early
sign. There is a high incidence of hernia, undescended
testicles, and kidney abnormalities in children with this
condition. Radiographs show the ossic nucleus of the
femoral head combined with the widened articular
cartilage space compared with the opposite hip.
Iliopsoas tendinitis. This tendinitis is caused by
frequent repetitive exions of the hip joint and is common in weight lifters, oarsmen, and football players.
The patient complains of mildly intense groin pain on
the anterior hip, which worsens with movement. An
acute injury involves forced extension of a exed leg,
and in younger age-groups, radiographic evaluation is
done if evulsion of the epiphysis is suspected. Test for
iliopsoas tendinitis by having the seated patient place
the heel of the affected leg on the knee of the other leg.
This movement will create pain and a tense iliopsoas
muscle.
Proximal bula fracture. Most proximal bula
fractures are caused by direct trauma to the lateral leg.
However, some fractures can be the result of forces
transferred from a lateral malleolar injury of the ankle,
especially when the force is a combination of compressive and rotational trauma. The peroneal nerve and
anterior tibial artery pass near the bular head, thus
injury to either of these structures can be a complication of a proximal bular fracture. If foot drop is present or a diminished dorsalis pedal pulse is noted,
the patient needs immediate referral to an orthopedic
surgeon (Figure 20-7).
Stress fracture. Stress fractures occur in adolescents
whose bodies are not able to accommodate an increase in
intensity of training. Patients will note pain with activity
several weeks after beginning a sport. Injury progresses
from trabecular microfractures in the bone to the osteoclastic action exceeding the rate of osteoblastic bone
formation resulting in the bone breaking. Plain radiographs may not demonstrate injury, so MRI used to
identify location of injury and CT is used for follow up.
Knee
Chondromalacia patellae. Chondromalacia of the
patella is a change in the patellofemoral joint cartilage,
which most often occurs in adolescent females. The
condition can be caused by trauma, anatomical anomalies, and misalignment of the patella. Softening of joint
Chapter 20 • Limb Pain 257
FIGURE 20-7 Typical appearance of a proximal fibular fracture.
(From Crowther CL: Primary orthopedic care, ed 2, St Louis,
2004, Mosby.)
cartilage, tufts of patellar cartilage, ssures, or ulcers
occur. Patients present with anterior knee pain that is
worse while climbing stairs or biking. Radiographic
studies of the knee, including tangential and sunrise
views, show irregularities of the patellofemoral joint.
Patellar tendinitis (jumper’s knee). This overuse
syndrome is characterized by inammation in the distal extensors of the knee joint. Patellar tendinitis is
more common in athletes who habitually place excessive strain on their knees from jumping or running.
Determine the quadriceps (Q) angle by measuring the
angle between the center of the patella to the anterior
superior iliac spine and from the center patella to the
tibial tubercle. An angle greater than 10 degrees in
males and 15 degrees in females suggests patellar tendinitis. Persons affected complain of dull, achy knee
pain that may have associated clicking or popping. Associated malalignment from femoral anteversion or
ankle varus may be present.
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Medial collateral ligament sprain. Medial collateral ligament injuries are common and are the result of
valgus stress to the knee. The patient limps soon after
the injury and may or may not have pain. On physical
examination, there is mild effusion and point tenderness over the medial collateral ligament. To test for
stability of the medial collateral ligament, the knee is
exed about 30 degrees with the patient supine, and
one hand is placed over the lateral knee with the other
around the ankle. Apply medial pressure to the knee
while pulling the ankle outward. An instability of
the medial collateral ligament produces a sensation of
opening the medial aspect of the joint. Applying lateral
pressure in the same knee position tests for lateral
ligament sprain. A radiograph is obtained to rule out
fracture.
Medial meniscus tear. Medial meniscus injuries,
more common than lateral meniscus injuries, occur
after a twisting injury to the knee. The patient has pain,
difculty exing the knee, and difculty bearing
weight. There often is a clicking or catching in the
knee joint, and the joint may be swollen and tender. To
examine for medial meniscus injury, perform the McMurray test to assess for clicking, locking, or a springy
end point of motion. With the patient supine, place one
hand under the heel and ex the knee 90 degrees with
slight abduction. Apply a lateral and medial force to
the knee while extending and adducting it. A palpable
or audible click indicates medial meniscus injury.
Anterior cruciate ligament tear. Ligaments may
be stretched or torn if the knee is twisted or hyperextended. The ACL, located in the center of the knee, is
one of the most common ligaments damaged in knee
injuries. An ACL injury is often associated with an audible pop and a giving-way sensation in the knee, often
with swelling from hemarthrosis. Physical examination
reveals a positive Lachman test. With the patient supine
and the knee exed 20 to 30 degrees, anchor the patient’s foot to the table; then pull the tibia forward.
Anterior motion is a sensitive test for ACL laxity.
Osgood-Schlatter disease. This condition, most
common in adolescent males, is a painful swelling of
the anterior aspect of the tibial tubercle. It is caused by
strenuous activity, especially of the quadriceps muscles. The patient will often limp, and the pain will be
worse with activities such as stair climbing and kneeling. Examination will reveal a warm, swollen, tender
tibial tubercle, and exion and extension will increase
pain intensity. Joint examination of the knee is normal.
Baker cyst (popliteal cyst). A popliteal cyst occurs
when uid from the knee joint enters the connecting
bursa and becomes trapped. Patients complain of a fullness or swelling of the posterior knee and calf pain
aggravated by walking and alleviated by rest. Examination of the knee focuses on assessment of a change in
consistency of the mass on extension (hardening) and
exion (softening), called Foucher sign. Foucher sign is
negative with a Baker cyst and positive with a tumor or
popliteal aneurysm. The cyst can rupture and cause
edema and tenderness of the lower extremity with a
positive Homans sign. Ultrasound will detect the cyst or
recently ruptured cyst.
Ankle and Foot
Ankle sprain (inversion or eversion). The most
common mechanism of ankle injury is an inversion
force that stresses the lateral ligamentous support of the
joint. The lateral ligaments are of greater length than the
medial ligaments and are more predisposed to injury.
An audible pop or tear implies a rupture or tear of the
ligament. Swelling of the ankle within minutes of injury
indicates bleeding and soft tissue trauma. Patients with
a ligamentous injury will generally be able to walk and
bear weight on the injured foot, even though it may be
uncomfortable. Examine the injured joint by palpating
the course and attachment points of the ligaments and
perform joint ROM to test for ligamentous integrity.
Shin splints (medial tibial stress syndrome).
Shin splints are an inammation of the origin of muscles on the shaft of the tibia caused by overuse, often
by running athletes. Patients report achy pain and tenderness over the medial tibia that increases with exercise, especially running, and improves with rest. A
radiograph of the tibia will exclude fracture.
Achilles tendinitis. The gastrocnemius and soleus
muscles conjoin to form the Achilles tendon. Inammation of this tendon creates pain and swelling where
the tendon inserts into the calcaneus, and a patient will
report a tightness of the tendon that makes walking or
running difcult. Tendinitis may be caused by overuse,
especially running, or by decreased vascularity to the
tendon sheath. Examination reveals tenderness over
the Achilles tendon with palpation and ankle ROM,
especially with dorsiexion, crepitus over the tendon
with motion, and weakness of the calf muscles.
Plantar fasciitis. Plantar fasciitis, which affects
women twice as often as men, is caused by chronic
weight-bearing stress when laxity of foot structures
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allows the talus to slide forward and medially, the calcaneus to drop, and plantar ligaments and fascia to
stretch. Persons who are obese or who engage in excessive standing are at greatest risk. Pain is worse on
awakening and is relieved with non–weight-bearing
activity. Tendons and joints become inamed, and
muscles spasm because of the misalignment of structures. Patients often complain of heel pain.
Muscle Pain (Myalgia)
Viral Infections
Viral infections can produce diffuse myalgias that
are usually associated with fever, chills, upper respiratory tract symptoms, and malaise. A patient with
inuenza will have intense myalgia and high fever,
and appear quite ill. Since viral illnesses are highly
contagious, epidemics in both children and adults
in a community may be a useful clue to diagnosis. A
paraviral IgM titer is diagnostic of an acute parvovirus B19 infection.
Psychogenic
Pain that is diffuse, varies in pattern, and is unaffected
by activity or rest may be psychogenic in origin. A
careful history may reveal any secondary gain the patient may derive from the pain and suggest the presence of an anxiety or depression disorder. On examination, the patient may display facial expressions and
descriptions of discomfort to palpation and movement
that are inconsistent. This diagnosis involves excluding
other causes.
Fibromyalgia
Fibromyalgia is a syndrome characterized by chronic
fatigue, generalized musculoskeletal pain, and multiple
trigger points of pain on physical examination. It affects primarily women between 20 and 50 years of age.
Other symptoms associated with this syndrome include
stage IV sleep disturbance, anxiety or depression, obsessive-compulsive behavior, and irritable bowel syndrome. Symptoms are exacerbated by stress. Physical
examination shows focal tenderness without signs of
synovitis.
Systemic Disorders
Acute Leukemia
Leukemia is the most common cancer in children, and
bone and joint pain is the most common presenting
complaint. The bone pain is diffuse and nonspecic,
and may extend to adjacent joints. Laboratory ndings
may show the WBC count as elevated, depressed, or
normal. Severe anemia is common as is a depressed
platelet count. Radiographs of the limb at the distal end
of the femur and the proximal end of the tibia show
abnormal areas of radiolucency.
Sickle Cell Disease
Sickle cell disease is a genetic disorder characterized
by production of hemoglobin S, an anemia secondary
to short erythrocyte survival, and sickle-shaped
erythrocytes. It affects mainly African American,
Mediterranean, and Southeast Asian population
groups. Sickle cell disease manifests itself after the
rst 6 months of life. The child presents with painful
or vaso-occlusive crises characterized by symmetri-
cal, painful swelling of the hands and feet. Older
persons report pain in long bones and joints, abdomi-
nal pain, decreased appetite, fever, and malaise. The
laboratory ndings reveal a hemoglobin S genotype
and anemia, but ndings can vary depending on the
hemoglobin genotype, age, gender, and presence of
other organ involvement.
Systemic Lupus Erythematosus
SLE is a systemic inammatory condition that occurs
most often in women. It is characterized by arthritis
that commonly involves the small joints of the hands,
wrists, ankles, and knees, as well as malar rash, oral
ulcers, glomerulonephritis, hematological disorders,
and psychological symptoms. The pain is transient but
severe. Laboratory ndings show leukopenia with neu-
trophils predominating the peripheral count, and the
ANA is positive.
Lyme Arthritis
The bite of the deer tick transmits the spirochete
B. burgdorferi. Patients may not recall a tick bite but
will have been in an endemic area. The presenting com-
plaints in Lyme disease are diffuse joint pain and swell-
ing, a targetlike skin rash (erythema migrans), fever,
and chills. These symptoms may be present for weeks
before the spirochete spreads via blood and lymph tis-
sue to the myocardium and central nervous system. A
chronic arthritis may appear months after the initial in-
fection. The arthritis is asymmetrical and occurs in the
large joints. The knee is a commonly affected joint. The
patient has an antalgic limp with diffuse swelling and
warmth of the knee joint anteriorly, as well as local
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synovial thickening. Laboratory diagnosis reveals elevation of immunoglobulin M (IgM) titers and IgG antibodies against the spirochete. The ESR is elevated.
Neuroblastoma
Neuroblastoma is a malignant tumor that usually occurs in children under 5 years of age. It originates from
cells in the sympathetic ganglia and adrenal medulla
but can arise from any part of the sympathetic nervous
system and metastasize to the bone. The presenting
complaint may be varied, but bone pain, limp, pallor,
and fatigue may be present. CT or MRI is used to identify the primary location of the tumor. In the urine,
3-methoxy-4-hydroxymandelic acid and homovanillic
acid levels are elevated.
Osteogenic Sarcoma
Osteogenic sarcoma is a tumor that occurs in persons
10 to 25 years old, with the most common site being the
distal femur or the proximal tibia. The patient initially
complains of local intermittent pain that quickly progresses to a constant and severe pain, and an antalgic
limp may develop. Palpation reveals tenderness over
the area affected. Laboratory ndings show an increase
in serum alkaline phosphatase level; radiograph shows
a “sunburst” image.
Nerve Entrapment Syndromes
Thoracic Outlet Syndrome
Thoracic outlet syndrome is the result of compression of nerve and vascular structures in the neck
area. Arterial compression creates pallor and decreased pulses and weakness, with eventual skin and
nail atrophy in the affected extremity. Nerve compression creates paresthesias, dysesthesias, and
pain. History may disclose that the patient sleeps
with the arm extended against the head, causing
morning symptoms of pain and paresthesias. Reaching, working with the arm raised, and lifting exacerbate pain. Other risk factors include a rounded,
sagging shoulder posture and shoulder muscle
deformities. A common compression occurs with the
cervical rib compressing the subclavian artery. A
bruit may be heard over the supraclavicular fossa.
Electromyographic studies help to delineate the
specic nerve involvement; however, they may not
identify the vascular involvement.
Carpal Tunnel Syndrome
Carpal tunnel syndrome involves entrapment of the
median nerve in the dominant hand, resulting from repeated strain that causes thickening of the exor tendon sheath. A dull, achy pain is felt across the wrist and
forearm with paresthesia, weakness, or clumsiness of
the hand; atrophy; dry skin; and skin color changes of
the hand secondary to impaired nerve innervation.
Symptoms are often worse at night. History reveals
repetitive activity of the upper extremity. Carpal tunnel
syndrome most often occurs in women and in persons
older than 30 years. Examination discloses dry skin on
the thumb, index nger, and middle nger (median
nerve distribution). Thenar atrophy may be present.
Tinel sign and Phalen test are positive (Table 20-2).
Peroneal Nerve Compression
Peroneal nerve compression can be caused by a cast,
sports injury, or trauma. Pain is felt across the head of
the bula and can result in footdrop.
Tarsal Tunnel Syndrome
The posterior tibial nerve is involved, and pain is felt
across the ankle and proximal foot. Tarsal tunnel syndrome is occasionally associated with motor weakness
of the proximal toe exors. Patients may not remember
a specic onset but report pain and weakness of the
foot muscles. Tapping the posterior tibial nerve posterior and inferior to the medial malleolus elicits pain.
Ask the patient about shoe t and use of any orthotic
devices.
Neuritis
Vascular metabolism affected by systemic disorders
such as diabetes mellitus can cause a nerve to become
ischemic, producing toxins that can directly damage
the nerve. Inammation can be of the nerve axon,
myelin sheath, or both. Soft tissue inammation contributing to neuropathy can be caused by collagen
disorders (e.g., SLE, scleroderma).
Diabetes mellitus is commonly associated with
sensory peripheral neuropathy and results in pain
and sensory loss that is more intense in the lower
extremities.
Alcoholism is associated with distal, demyelinating
neuropathy that may resolve with cessation of alcohol
ingestion.
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